Referral Form
Refer someone with dementia to Dementia Auckland
To refer someone to Dementia Auckland, you can fill out the online form and submit it electronicaly - or you can use the downloadable PDF Dementia Auckland Referral Form Please print it off, fill it in and fax or post it to us.
Referrer name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Phone number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Position {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Organisation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Person living with dementia information
Surname {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
First Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Ethnicity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
NHI Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Diagnosis {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Carer Information
Surname {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
First Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Relationship to person with dementia {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Contact details (of the carer)
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Other relevant information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Free services include:
- Information about all dementias
- Education courses for carers
- Support groups for carers
- Activity group for person with dementia
- Phone consultations
- Home-based dementia support
- Referral to other appropriate service providers
Service area covered is from Counties/Manukau border through to Rodney District.
For all services available please call 09 622 4230